Patients with NASH had higher NLR than those without (mean: 2.6 vs. 1.9, respectively, P < 0.001). The NLR correlated positively with NAFLD activity score, pro-inflammatory cytokines, and CRP (P < 0.001). In addition, patients with advanced fibrosis stages (F3–4) had a higher NLR than those with mild (F1–2) (mean 2.5 vs.1.8, respectively, P < 0.001); with the highest specificity (79.2%) and sensitivity (69.4%) for identification of advanced fibrosis at NLR cutoff of 2.4 (AUC = 0.732, P < 0.001). Here, CRP is linked to metabolic dysfunction-associated steatohepatitis.